HIPEC and Cytoreductive Surgery for Mesothelioma

What Is HIPEC?

Hyperthermic intraperitoneal chemotherapy, or HIPEC, combines heated chemotherapy with surgery to treat peritoneal mesothelioma. Cytoreductive surgery removes the bulk of tumors. Then, warmed chemotherapy drugs are infused and circulated throughout the peritoneal cavity to treat any remaining cancer cells.

Key Facts About HIPEC for Mesothelioma

1. HIPEC has the best survival rate of any treatment for peritoneal mesothelioma.
2. After HIPEC surgery, the 5-year survival rate for peritoneal mesothelioma is 69%.
3. HIPEC causes fewer side effects than whole-body or systemic chemo.
4. HIPEC can safely give higher drug doses than whole-body chemo.

HIPEC surgery significantly benefits at least half of peritoneal mesothelioma patients eligible for the procedure. Delivering heated chemotherapy throughout the abdomen prevents many side effects from systemic chemotherapy because the medication does not leave the abdominal cavity. Overall, HIPEC surgery reduces symptoms and prolongs survival.

Who Is Eligible for HIPEC Treatment?

A good candidate for HIPEC surgery is younger and must be healthy enough to withstand the surgery and recovery period. HIPEC is an aggressive treatment and involves a long surgery that may last 12 hours.

HIPEC Eligibility

• Be healthy enough for surgery.
• Not have heart disease or other serious chronic conditions.
• Not have more than one bowel obstruction or partial obstruction.
• Have a low peritoneal cancer index score, which estimates cancer growth and spreading.
• Have an epithelial cell type (other cell types are carefully considered).

Doctors look for patients who are otherwise healthy except for their cancer diagnosis. They conduct assessments to determine a patient’s overall health, which they call performance status.

A 2021 research study by Dr. Paul Sugarbaker determined that age had the greatest impact on survival following a HIPEC procedure. Contraindications of HIPEC can include severe chronic illnesses, heart disease and liver disease. A diagnosis with epithelial cell type improves the chances that HIPEC will be effective.

How Does HIPEC Surgery Work on Mesothelioma?

HIPEC works in two phases: cytoreductive surgery to remove tumors and a heated chemotherapy “bath” to kill remaining cancer cells. This technique has produced the longest survival rates of any therapy for peritoneal mesothelioma with at least half of patients living longer than five years.

Phase 1: Cytoreductive Surgery

First, doctors perform a peritonectomy using cytoreductive surgery techniques to remove as many tumors as possible from the abdominal cavity. This technique is also known as debulking surgery because it aims to remove the bulk of visible tumors.

Removing as much cancer as possible first is crucial. Heated chemotherapy without surgery is less effective since the drugs cannot penetrate deep into tumors. In some cases, tumor removal is impossible, and patients must explore other treatment options.

Phase 2: Chemotherapy Bath

Mesothelioma doctors target the remaining cancer cells with heated chemotherapy immediately after surgery. This chemotherapy bath extends survival and helps prevent cancer recurrence.

The HIPEC machine allows doctors to insert catheters into the abdominal cavity and connect them to the perfusion system, which heats the chemotherapy solution and pumps it to and from the body. Chemotherapy drugs flow between the patient and the perfusion system for about one hour. Then doctors drain the medicated solution from the body. Surgeons rinse the cavity with a saline solution before removing the catheter and closing the incision.

The usual chemotherapy drugs, including carboplatin, cisplatin, doxorubicin, gemcitabine and pemetrexed, have been used for heated chemotherapy. The procedure, including surgery and HIPEC, can take six to 18 hours. The surgery takes longer when the cancer is more widespread.

HIPEC Risks and Side Effects

The risk of complications with HIPEC surgery varies by surgeon and cancer center, but the overall risk ranges from 4.5% to 19%. The most common serious complications include intestinal leaks, kidney failure, pancreatic inflammation, sepsis and a drop in blood cells.

The most common side effects of HIPEC include nausea, vomiting, pain and weight loss.

Side Effects of HIPEC Surgery

• Bleeding
• Wound infections
• Urinary tract infections
• Blood clots
• Pneumonia
• Bowel obstruction
• Disruption of normal bowel motility (which reduces appetite)
• Fistula (a connection between the skin and intestines)
• Myelosuppression (bone marrow produces fewer platelets and blood cells)
• Sepsis

Many HIPEC surgery side effects are also seen with other surgeries, including delayed wound healing, bleeding, sepsis and bowel obstruction. Eligibility requirements help ensure you are a good candidate for HIPEC and have a lower risk of severe side effects.

Recovery

The recovery time for HIPEC treatment is around two to three months. Your treatment team will review everything you need to know about the recovery process, including how to care for your incision wounds and promote healing.

For many people, the most challenging aspect of recovery is fatigue. It may take several months until you feel back to normal. Until then, staying active (within your limits) and maintaining good nutrition to keep your energy levels up is essential.

If you develop any worsening side effects or conditions, call your doctor to discuss ways to manage or treat them. For example, a wound infection requires antibiotics and should be treated quickly.

How to Access HIPEC Treatment

Cytoreductive surgery with HIPEC is not widely available at cancer centers throughout the U.S. This procedure is not offered as a standard treatment option at all mesothelioma cancer centers because of the complexity of cytoreductive surgery. Some centers lack familiarity with the HIPEC procedure and don’t have the required equipment.

To learn more about HIPEC and whether you qualify, schedule a surgical consultation. During a consultation, you meet with the surgeon and surgical team members either virtually or in person). You can ask questions and address any concerns with the team.

The surgical team then reviews your medical records to determine if you qualify. If so, the surgeon will discuss the risks and benefits of surgery with you. You will learn more about the surgery, including how to prepare and what to expect during recovery.

Impact on Life Expectancy for Mesothelioma Patients

HIPEC surgery is successful in about half of the peritoneal mesothelioma patients who undergo the procedure, and it helps them live at least five years on average. It is most successful among younger, early-stage patients with fewer tumors.

Repeat HIPEC surgery patients have an average survival of 67.7 months, or 5.6 years, according to a March 2022 study published in Annals of Surgical Oncology.

Earlier studies reported varying degrees of success, with several reporting great success even two decades ago. For example, stage 1 HIPEC surgery patients had a five-year survival rate of 87% in a 2011 study published in Cancer. Additionally, all stages combined had a median survival of 92 months, or 7.6 years, according to a 2003 study published in the Journal of Clinical Oncology.

Medical Studies Supporting HIPEC

Numerous studies show HIPEC surgery drastically improves peritoneal mesothelioma life expectancy in about half of the patients who undergo the procedure. In four major studies, the median survival rate for mesothelioma after HIPEC surgery was just over five years.

Research on HIPEC

• Dr. Paul Sugarbaker’s Study: In 2017, Dr. Paul Sugarbaker, who helped pioneer HIPEC surgery, published a study on long-term treatment approaches for peritoneal epithelial mesothelioma. Sugarbaker’s study used cytoreductive surgery and HIPEC and included patients who received one or two additional types of chemotherapy. For example, some patients received early postoperative intraperitoneal chemotherapy or EPIC. Other patients received EPIC plus adjuvant normothermic intraperitoneal chemotherapy, also called NIPEC, used long-term to prevent a recurrence.
• Multicenter Study: One of the most extensive multicenter studies on HIPEC surgery reported a median survival of 53 months or 4.5 years. One patient survived for more than 19 years after the procedure. Survival rates for one, three and five years were 81%, 60% and 47%, respectively.
• Peritoneal Malignancy Institute Study: In a 2021 U.K. study, 40 patients underwent cytoreductive surgery with HIPEC for multicystic peritoneal mesothelioma, considered a benign form of the disease that rarely turns malignant. The average predicted disease-free interval was 11 years, with a 5-year progression-free survival of more than 80%. This means most people did not see any disease progression for five years after the procedure.
• Washington Cancer Institute Study: In 2015, researchers from Washington Cancer Institute’s Program in Peritoneal Surface Malignancy published results from a study on the survival outcomes of using HIPEC surgery a second time to treat a recurrence. Survival after a second HIPEC surgery was 4.5 years compared to 6.4 years after the first HIPEC surgery. These results suggest HIPEC surgery is an effective second-line therapy for recurrent peritoneal mesothelioma.

Dr. Paul Sugarbaker’s study reported five-year survival rates of 44% for patients treated with cytoreduction and HIPEC, 52% for patients who also received EPIC, and 75% for patients who also received EPIC and NIPEC. Sugarbaker’s results indicate that long-term, nonheated intraperitoneal chemotherapy is an effective maintenance therapy that improves survival following surgery.

The medical community continues researching the best chemotherapy temperature and exposure time of drug combinations. As this research advances, survival outcomes should continue to improve.

Common Questions From HIPEC Patients

Is HIPEC and cytoreductive surgery painful?

Yes, patients often report temporary pain following cytoreductive surgery with HIPEC. Patients may experience pain along surgical incisions, inflammatory pain and neuropathic or nerve pain.

How much does HIPEC treatment cost?

The cost of cytoreductive surgery with HIPEC ranges from approximately $38,000 to $49,000. According to a 2020 study published in the Annals of Surgical Oncology, patients with health insurance have an average direct cost of about $20,500.

Is HIPEC surgery dangerous?

The mortality rate associated with HIPEC surgery is about 1.1%, and the rate of serious complications ranges from 4.5% to 19%, according to a 2019 study published in JAMA and a 2016 study published in the Indian Journal of Surgical Oncology.

Do you lose your hair with HIPEC?

Significant hair loss is very rare with HIPEC because the administration of chemotherapy is local to the abdominal lining. This targeted application minimizes medication exposure to the rest of the body. As a result, typical side effects of chemotherapy, including hair loss, are reduced or avoided.

What cancers are treated with HIPEC?

The cancers treated with HIPEC surgery are peritoneal mesothelioma, ovarian cancer, stomach (gastric) cancer, colorectal cancer and pseudomyxoma peritonei, the latter of which is a mucinous tumor of the appendix.

Is HIPEC available for pleural mesothelioma patients?

A procedure known as hyperthermic intrathoracic chemotherapy or HITHOC, delivers chemotherapy directly into the pleural lining that surrounds the lungs. A study led by Dr. David Sugarbaker reported that HITHOC improved survival by 12.5 months in pleural mesothelioma patients eligible for surgery.

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